IKHLAS PHM VIP MEDICAL TAKAFUL                                        (Hospitalisation and Surgical Takaful Coverage)WHERE...
GENERAL PROVISIONS1.   PERSONS ELIGIBLE     Persons eligible to be covered under this Certificate are:-     (a)    the Par...
SECTION A                                              MEDICAL EXPENSES BENEFITS                                          ...
16   COVERED PERSON shall mean the person described in the Certificate Schedule including his/her Dependent (if     applic...
(b)     To repair, revise or reconstruct any organ or body part.    (c)     To reduce by manipulation a fracture or disloc...
8    POST-HOSPITALISATION TREATMENT     Reimbursement of the Reasonable and Customary Charges incurred in Medically Necess...
20   OUT-PATIENT CANCER TREATMENT     If a Covered Person is diagnosed with Cancer as defined below, the Company will reim...
EXCLUSIONS FOR SECTION AThis contract does not cover any hospitalisation, surgery or charges caused directly or indirectly...
SPECIFIC CONDITIONS FOR SECTION A1.   CONVERSION CERTIFICATES (applicable only if specified in the Certificate Schedule)  ...
SECTION B                                             PERSONAL ACCIDENT BENEFITS                                          ...
- 2 phalanges                                                                                 4%                        - ...
EXCLUSIONS FOR SECTION BThis Takaful shall not apply to any accident consequent upon or caused by or contributed by or ari...
GENERAL CONDITIONS1.   ALTERATIONS     The Company reserves the right to amend the terms and provisions of this Certificat...
7.    CLAIM PROCEDURES      (a)    The Participant shall within thirty (30) days of a Disability that incurs claimable exp...
16.   MISREPRESENTATION / FRAUD      If the proposal or declaration of the Covered Person is untrue in any respect or if a...
25.       SURPLUS          At each financial year-end, the Actuary will assess the surplus position of the Risk Fund.     ...
CLAUSES/ENDORSEMENTS/PERILS & WARRANTIESThe following perils, clauses, endorsements and/or warranties only apply to this c...
IKHLAS PHM VIP MEDICALTAKAFUL                                       (Perlindungan Penghospitalan dan Pembedahan Takaful)DI...
PERUNTUKAN-PERUNTUKAN AM1.   ORANG YANG LAYAK     Orang yang layak untuk dilindungi di bawah Sijil ini adalah:     (a)   P...
SEKSYEN A                                         MANFAAT PERBELANJAAN HOSPITAL                                           ...
13.   PENGHOSPITALAN bermaksud dimasukkan ke Hospital sebagai pesakit dalaman yang berdaftar untuk rawatan      yang Perlu...
28.   SAKIT, WABAK ATAU PENYAKIT bermaksud keadaan fizikal yang ditunjukkan dari segi patologi berbeza daripada      keada...
6    UJIAN DIAGNOSTIK PRA-HOSPITAL     Pembayaran balik bagi Bayaran Munasabah dan Biasa Diamalkan untuk ECG, sinar-X dan ...
PHM Cert
PHM Cert
PHM Cert
PHM Cert
PHM Cert
PHM Cert
PHM Cert
PHM Cert
PHM Cert
PHM Cert
PHM Cert
PHM Cert
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PHM Cert

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PHM Cert

  1. 1. IKHLAS PHM VIP MEDICAL TAKAFUL (Hospitalisation and Surgical Takaful Coverage)WHEREAS the Participant named in the Certificate Schedule has applied to Takaful Ikhlas Sdn Bhd (hereinafter called "theCompany") or the takaful herein described and has paid or agreed to pay the contribution stated in the Certificate Schedule asconsideration for the takaful hereinafter contained.NOW THIS CERTIFICATE WITNESSETH that if the Covered Person is confined to a hospital for treatment or is surgicallytreated as a day case during the Period of Takaful stated In the Certificate Schedule, the Company will pay to the Participant orhis legal personal representative the sum or sums stated in the Certificate Schedule. Payment is subject to reasonable andcustomary charges and will only be made upon receipt and approval of proofs of expenses incurred.THIS CERTIFICATE is subject to the provisions, conditions and limitations as contained herein or as may be endorsed hereon. SCHEDULE OF BENEFITS DESCRIPTION BENEFIT SECTION A MEDICAL EXPENSES BENEFIT PVM 1(a) PVM 2(a) 1. Hospital Room & Board, daily maximum up to 365 days 500 350 2. Intensive Care Unit, daily maximum up to 365 days 3. Hospital Supplies & Services 4. Pre-Surgical Consultation & Diagnosis, within 31 days prior to surgery 5. Surgical Fees (including Anaesthetist Fee and Operating Theatre) and post-surgery care up to 31 days 6. Pre-Hospital Specialist Consultation & Diagnostic Tests, within 31 days prior to admission As Charged 7. In-Hospital Physician Visit, daily maximum up to 365 days (subject to reasonable and customary 8. Post Hospitalisation Treatment, within 60 days from the date of charges) discharge 9. Ambulance Fees 10. Emergency Accidental Outpatient Treatment, per accident including follow-up up to 31 days 11. Emergency Dental Treatment, per accident including follow-up up to 31 days 12. Covered Child s Daily Guardian Benefit, daily maximum up to 365 Covered Covered days 13. Medical Report Fee, per disability 100 100 14. Government Service Tax Covered Covered 15. Funeral Expenses 5,000 3,000 16. Hospitalisation Cash Benefit, up to 60 days (payable from 3rd day 500 300 onwards) 17. Outpatient Cancer Treatment , per year 60,000 36,000 18. Outpatient Kidney Dialysis , per year 60,000 36,000 Limit Per Disability 200,000 150,000 Overall Annual Limit 600,000 450,000 LIFETIME LIMIT 600,000 450,000 SECTION B PERSONAL ACCIDENT BENEFIT Accidental Death & Permanent Disablement 200,000 150,000 1
  2. 2. GENERAL PROVISIONS1. PERSONS ELIGIBLE Persons eligible to be covered under this Certificate are:- (a) the Participant aged below 80 years; (b) the Participant s legal spouse aged below 80 years, unless legally separated from the Participant; and (c) the Participant s child who has attained the age of 30 days and is an unmarried person, is financially dependent upon the Participant and is under the age of 19 or up to the age of 23 for those registered as full time students at a recognized educational institution.2. PERIOD OF COVER AND RENEWAL This Certificate shall become effective as of the date stated in the Schedule. The Certificate Anniversary shall be one year after the effective date and annually thereafter. On each such anniversary, this Certificate is renewable at the contribution rates in effect at that time as notified by the Company. This Certificate will be renewable at the option of Participant subject to the terms, conditions and termination at each of the anniversary of the Certificate date. The renewal contribution payable is not guaranteed and the Company reserves the right to determine the contribution applicable specifically to each Participant at the time of renewal. During renewal, the terms and conditions of coverage shall not be amended, except where a particular disability has reached the maximum limit per disability. In such situation, the Company reserves the right to specifically exclude such disability from the certificate. This Certificate is renewable at the option of Participant until the occurrence of any of the following: (a) non payment of contribution or contribution not made on time (b) fraud or misrepresentation of material fact during application (c) the Certificate is cancelled at the request of the Participant (d) total claims of the Certificate have reached the lifetime limit specified and/or on the death of the Covered Person (e) the Covered Person ceases to qualify as a dependant based on the definition of the Certificate (f) the Covered Person attains the coverage age limit specified (g) termination of coverage for all Certificates in a certain market and the Company withdraws this Certificate completely from the market in accordance with the Portfolio Withdrawal Condition. The Company shall give the Participant a 30 day written notice in the event of revision of contribution or portfolio withdrawal.3. GEOGRAPHICAL TERRITORY All benefits provided in this Certificate are applicable worldwide for twenty-four (24) hours a day.4. SUCCEEDING PARTICIPANT (a) In the event of death of the Certificate Owner while this Certificate is in force, the Certificate Owner s legal spouse may become the new Certificate Owner upon signing of a new aqad, and all references in this Certificate to the Certificate Owner shall hereafter mean such spouse. (b) When a Covered Person ceases to be a dependant child, the Covered Person may continue to renew the Certificate in the Covered Person s own name as a Participant and all references in this Certificate to the Participant shall thereafter mean such Covered Person. 2
  3. 3. SECTION A MEDICAL EXPENSES BENEFITS DEFINITIONS1 ACCIDENT shall mean a sudden, unintentional, unexpected, unusual and specific event that occurs at an identifiable time and place which shall, independently of any other cause, be the sole cause of bodily injury.2 ANY ONE DISABILITY shall mean all of the periods of disability arising from the same cause including any and all complications there from except that if the Covered Person completely recovers and remain free from further treatment (including drugs, medicines, special diet or injection or advice for the condition) of the disability for at least ninety (90) days following the latest date of discharge and subsequent disability from the same cause shall be considered as though it were a new disability.3 AS CHARGED refers to actual charges incurred for reasonable, necessary and customary medical care provided in the treatment of a covered disability.4 CHILD shall mean any person who has attained the age of 30 days and is an unmarried person is financially dependent upon the Participant and is under the age of 19 or up to the age of 23 for those registered as full time students at a recognized educational institution.5 CONGENITAL CONDITIONS shall mean any medical or physical abnormalities existing at the time of birth, as well as neo-natal physical abnormalities developing within 6 months from the time of birth. They will include hernias of all types and epilepsy except when caused by a trauma which occurred after the date that the participant was continuously covered under this Certificate.6 DOCTOR or PHYSICIAN or SURGEON shall mean a registered medical practitioner qualified and licensed to practice western medicine and who, in rendering such treatment, is practicing within the scope of his licensing and training in the geographical area of practice, but excluding a doctor, physician or surgeon who is the Participant himself.7 DENTIST shall mean a person who is duly licensed or registered to practice dentistry in the geographical area in which a service is provided, but excluding a physician or surgeon who is the Participant himself.8 DEPENDANT shall mean any of the following persons: (a) a legally married spouse (b) unmarried children over 30 days old but under nineteen (19) years of age or twenty-three (23) years of age is still on full-time higher education, and who are not gainfully employed.9 DAY SURGERY - A patient who needs the use of a recovery facility for a surgical procedure on a pre-plan basis at the hospital/specialist clinic (but not for overnight stay).10 DISABILITY shall mean a Sickness, Disease, Illness or the entire Injuries arising out of a single or continuous series of causes.11 ELIGIBLE EXPENSES shall mean Medically Necessary expenses incurred due to a covered Disability but not exceeding the limits in the schedule.12 HOSPITAL shall mean only an establishment duly constituted and registered as a hospital for the care and treatment of sick and injured persons as paying bed-patients, and which: (a) has facilities for diagnosis and major surgery (b) provides 24 hours a day nursing services by registered and graduate nurses (c) is under the supervision of a Physician, and (d) is not primarily a clinic, a place for alcoholics or drug addicts, a nursing, rest or convalescent home or a home for the aged or similar establishment.13 HOSPITALISATION shall mean admission to a Hospital as a registered in-patient for Medical Necessary treatment for a covered Disability upon recommendation of a physician. A patient shall not be considered as an in-patient if the patient does not physically stay in the hospital for the whole period of confinement.14 INTENSIVE CARE UNIT shall mean a section within a Hospital which is designated as an Intensive Care Unit by the Hospital and which is maintained on a twenty-four (24) hour basis solely for treatment of patients in critical condition and is equipped to provide special nursing and medical services not available elsewhere in the Hospital.15 INJURY shall mean bodily injury caused solely by Accident. 3
  4. 4. 16 COVERED PERSON shall mean the person described in the Certificate Schedule including his/her Dependent (if applicable).17 LIFETIME LIMIT shall mean the maximum amount payable in the lifetime of the Covered Person. Once the lifetime limit is reached, the Certificate is automatically terminated. Where stated in the Certificate, the Iifetime limit shall apply.18 MALAYSIAN GOVERNMENT HOSPITAL shall mean a hospital which charges of services are subject to the Fee Act 1951, Fees (Medical) Order 1982 and/or its subsequent amendments if any.19 MEDICALLY NECESSARY shall mean a medical service which is: (a) consistent with the diagnosis and customary medical treatment for a covered Disability, and (b) in accordance with standards of good medical practice, consistent with current standard of professional medical care, and of proven medical benefits, and (c) not for the convenience of the Participant or the Physician, and unable to be reasonably rendered out of hospital (if admitted as an inpatient), and (d) not of an experimental, investigational or research nature, preventive or screening nature, and (e) for which the charges are fair and reasonable and customary for the Disability.20 OUT-PATIENT shall mean the Covered Person is receiving medical care or treatment without being hospitalised and includes treatment in a Daycare centre.21 OVERALL ANNUAL LIMIT Benefits payable in respect of expenses incurred for treatment provided to the Covered Person during the period of takaful shall be Iimited to Overall Annual Limits as stated in the Schedule of Benefits irrespective of the type/types of disability. In the event the Overall Annual Limit having been paid, all coverage for the Covered Person hereunder shall immediately cease to be payable for the remaining Certificate year.22 PARTICIPANT shall mean a person or corporate body to whom the Certificate has been issued in respect of cover for persons specifically identified as Covered Persons in this Certificate.23 CERTIFICATE YEAR shall mean the one year period including the effective date of commencement of takaful and immediately following that date, or the one year period following the Renewal or Renewed Certificate.24 PRE-EXISTING ILLNESS shall mean disabilities that the Covered Person has reasonable knowledge of. A Covered Person may be considered to have reasonable knowledge of a pre-existing condition where the condition is one for which:- (a) the Covered Person had received or is receiving treatment; (b) medical advice, diagnosis, care or treatment has been recommended; (c) clear and distinct symptoms are or were evident; or (d) its existence would have been apparent to a reasonable person in the circumstances.25 PRESCRIBED MEDICINES shall mean medicines that are dispensed by a Physician, a Registered Pharmacist or a Hospital and which have been prescribed by a Physician or Specialist in respect of treatment for a covered Disability.26 REASONABLE AND CUSTOMARY CHARGES shall mean charges for medical care which is medically necessary shall be considered reasonable and customary to the extent that it does not exceed the general level of charges being made by others of similar standing in the locality where the charge is incurred, when furnishing like or comparable treatment, services or supplies to individual of the same sex and of comparable age for a similar sickness, disease or injury and in accordance with accepted medical standards and practice could not have been omitted without adversely affecting the Covered Person s medical condition.27 RENEWAL OR RENEWED CERTIFICATE shall mean a Certificate which has been renewed without any lapse of time upon expiry of a preceding Certificate with the same content.28 SICKNESS, DISEASE or ILLNESS shall mean a physical condition marked by a pathological deviation from the normal healthy state.29 SPECIALIST shall mean a medical or dental practitioner registered and licensed as such in the geographical area of his practice where treatment takes place and who is classified by the appropriate health authorities as a person with superior and special expertise in specified fields of medicine or dentistry but excluding a physician or surgeon who is the Participant himself.30 SURGERY shall mean any of the following medical procedures: (a) To incise, excise or electrocauterize any organ or body part, except for dental services. 4
  5. 5. (b) To repair, revise or reconstruct any organ or body part. (c) To reduce by manipulation a fracture or dislocation. (d) Use of endoscopy to remove a stone or object from the larynx, bronchus, trachea, esophagus, stomach, intestine, urinary bladder, or urethra. DESCRIPTION OF BENEFITSSECTION A1 HOSPITAL ROOM AND BOARD Reimbursement of the Reasonable and Customary Charges Medically Necessary for room accommodation and meals. The amount of the benefit shall be equal to the actual charges made by the Hospital during the Covered Person s confinement, but in no event shall the benefit exceed, for any one day, the rate of Room and Board Benefit and the maximum number of days as set forth in the Schedule of Benefits. The Participant will only be entitled to this benefit while confined to a Hospital as in-patient.2 INTENSIVE CARE UNIT Reimbursement of the Reasonable and Customary Charges Medically Necessary for actual room and board incurred during confinement as an in-patient in the Intensive Care Unit of the Hospital. This benefit shall be payable equal to the actual charges made by the Hospital subject to the maximum benefit for any one day, and maximum number of days, as set forth in the Schedule of Benefits. Where the period of confinement in an Intensive Care Unit exceeds the maximum set forth in the Schedule of Benefits, reimbursement will be restricted to the standard Daily Hospital Room and Board rate. No Hospital Room and Board Benefits shall be paid for the same confinement period where the Daily Intensive Care Unit Benefits is payable.3 HOSPITAL SUPPLIES & SERVICES Reimbursement of the Reasonable and Customary Charges actually incurred for Medically Necessary general nursing, prescribed and consumed drugs and medicines, dressings, splints, plaster casts, x-ray, laboratory examinations, electrocardiograms, physiotherapy, basal metabolism tests, intravenous injections and solutions, administration of blood and blood plasma but excluding the cost of blood and plasma whilst the Covered Person is confined as an in- patient in a Hospital, up to the amount stated in the Schedule of Benefits.4 PRE-SURGICAL CONSULTATION & DIAGNOSIS Specialists fees for consultation, pathology and radiography following referral from a general practitioner, for each illness or injury requiring confinement in a hospital. Benefit is not payable for outpatient treatment (including medications and any subsequent consultations after the illness is diagnosed), nor if the patient is not subsequently surgically treated after such diagnostic services have been performed.5 PRE-HOSPITAL SPECIALIST CONSULTATION Reimbursement of the Reasonable and Customary Charges for the first time consultation by a Specialist in connection with a Disability within the maximum number of days as set forth in the Schedule of Benefit preceding confinement in a Hospital and provided that such consultation is Medically Necessary and has been recommended in writing by the attending general practitioner. Payment will not be made for clinical treatment (including medications and subsequent consultation after the illness is diagnosed) or where the Participant does not result in hospital confinement for the treatment of the medical condition diagnosed.6 PRE-HOSPITAL DIAGNOSTIC TESTS Reimbursement of the Reasonable and Customary Charges for Medically Necessary ECG, X-ray and laboratory tests which are performed for diagnostic purposes on account of an injury or illness when in connection with a Disability preceding hospitalisation within the maximum number of days and amount as set forth in the Schedule of Benefit in a Hospital and which are recommended by a qualified medical practitioner. No payment shall be made if upon such diagnostic services, the Participant does not result in hospital confinement for the treatment of the medical condition diagnosed. Medications and consultation charged by the medical practitioner will not be payable.7 IN-HOSPITAL PHYSICIAN VISIT Reimbursement of the Reasonable and Customary Charges by a Physician for Medically Necessary visiting an in- paying patient while confined for a non-surgical disability subject to a maximum of 1 visit per day not exceeding the maximum number of days as set forth in the Schedule of Benefit. 5
  6. 6. 8 POST-HOSPITALISATION TREATMENT Reimbursement of the Reasonable and Customary Charges incurred in Medically Necessary follow-up treatment by the same attending Physician, within the maximum number of days and amount as set forth in the Schedule of Benefits immediately following discharge from Hospital for a non-surgical disability. This shall include medicines prescribed during the follow-up treatment but shall not exceed the supply needed for the maximum number of days as set forth in the Schedule of Benefits.9 SURGICAL FEES Reimbursement of the Reasonable and Customary Charges for a Medically Necessary surgery by the Specialists, including pre-surgical assessment Specialist s visits to the Covered Person and post-surgery care up to the maximum of 31 days from the date of surgery, but within the maximum amount indicated in the Schedule of Benefits. If more than one surgery is performed for Any One Disability, the total payments for all the surgeries performed shall not exceed the maximum stated in the Schedule of Benefits.10 ANAESTHETIST FEE Reimbursement of the Reasonable and Customary Charges by the Anaesthetist for the Medically Necessary administration of anesthesia not exceeding the limits as set forth in the Schedule of Benefits.11 OPERATING THEATRE Reimbursement of the Reasonable and Customary Operating Room charges incidental to the surgical procedure.12 AMBULANCE FEES Reimbursement of the Reasonable and Customary Charges incurred for necessary domestic ambulance services (inclusive of attendant) to and/or from the Hospital of confinement. Payment will not be made if the Covered Person is not hospitalised and subject to the limits set forth In the Schedule of Benefits.13 EMERGENCY ACCIDENTAL OUTPATIENT TREATMENT Reimbursement of the Reasonable and Customary Charges incurred for up to the maximum stated in the Schedule of Benefits, as a result of a covered bodily injury arising from an Accident for Medical Necessary treatment as an outpatient at any registered clinic or hospital within 24 hours of the Accident causing the covered bodily injury. Follow up treatment by the same doctor or same registered clinic or Hospital for the same covered bodily injury will be provided up to the maximum amount and the maximum number of days as set forth in the Schedule of Benefits.14 EMERGENCY DENTAL TREATMENT Reimburses expenses incurred as a result of an injury to wholly sound natural teeth arising from an Accident for treatment as an outpatient at any registered dental clinic or hospital within twenty four (24) hours of the Accident causing Injury. Follow-up treatment by will be provided up to 31 days by the same dentist at the same registered dental clinic or Hospital.15 COVERED CHILD S DAILY GUARDIAN BENEFIT Reimburses (up to stipulated limits set forth on the Schedule of Benefits) the expenses for meals and lodging incurred to accompany a covered Child (aged below fifteen (15) years) in the hospital up to the maximum number of days set forth in the Schedule of Benefits.16 REIMBURSEMENT OF MEDICAL REPORT FEE It is hereby declared and agreed that notwithstanding anything contained herein to the contrary, the certificate is extended to reimburse Medical Report Fee not exceeding the amount stated in the Schedule of Benefits in respect of each disability.17 REIMBURSEMENT OF SERVICE TAX Reimburses the actual payable in respect of treatment received for illnesses or conditions covered under the Certificate.18 FUNERAL EXPENSES It is hereby declared and agreed that the Certificate is extended to pay a lump sum as specified in the Schedule of Benefits if the Covered Person dies during surgery or hospitalisation or within 14 days from the date of discharge from a Hospital.19 HOSPITALISATION CASH BENEFIT It is hereby declared and agreed that the Certificate is extended to pay, in addition to any other items reimbursable under any policy, a daily cash allowance for each day patient is confined to a Hospital as specified in the Schedule of Benefits 6
  7. 7. 20 OUT-PATIENT CANCER TREATMENT If a Covered Person is diagnosed with Cancer as defined below, the Company will reimburse the Reasonable and Customary Charges incurred for the Medically Necessary treatment of cancer performed at a legally registered cancer treatment centre subject to the limit of this disability as specified in the Schedule of Benefit. Such treatment (radiotherapy or chemotherapy excluding consultation, examination tests, take home drugs) must be received at the out-patient department of a Hospital or a registered cancer treatment centre immediately following discharge from Hospital confinement or surgery Cancer is defined as the uncontrollable growth and spread of malignant cells and the invasion and destruction of normal tissue which major interventionist treatment or surgery (excluding endoscopic procedures alone) is considered necessary. The cancer must be confirmed by histological evidence of malignancy. The following conditions are excluded:- (a) Carcinoma in situ including of the cervix; (b) Ductal Carcinoma in situ of the breast; (c) Papillary Carcinoma of the bladder & Stage I Prostate Cancer; (d) All skin cancers except malignant melanoma; (e) Stage 1 Hodgkin s disease; (f) Tumors manifesting as complications of AIDS. It is a specific condition of this Benefit that notwithstanding the exclusion of pre-existing conditions, this Benefit will not be payable for any Participant who had been diagnosed as a cancer patient and/or is receiving cancer treatment prior to the effective date of Takaful.21 OUT-PATIENT KIDNEY DIALYSIS TREATMENT If a Covered Person is diagnosed with Kidney Failure as defined below, the Company will reimburse the Reasonable and Customary Charges incurred for the Medically Necessary treatment of kidney dialysis performed at a legally registered dialysis centre subject to the limit of this disability as specified in the Schedule of Benefit. Such treatment (dialysis excluding consultation, examination tests, take home drugs) must be received at the out- patient department of a Hospital or a registered dialysis treatment centre immediately following discharge from Hospital confinement or surgery. Kidney Failure means end stage renal failure presenting as chronic, irreversible failure of both kidneys to function as a result of which renal dialysis is initiated. It is a specific condition of this Benefit that notwithstanding the exclusion of pre-existing conditions this Benefit will not be payable for any Participant who has developed chronic renal diseases and/or is receiving dialysis treatment prior to the effective date of Takaful. 7
  8. 8. EXCLUSIONS FOR SECTION AThis contract does not cover any hospitalisation, surgery or charges caused directly or indirectly, wholly or partly, by any one (1)of the following occurrences:1. Pre-existing illness.2. Any medical or physical conditions arising within the first thirty (30) days of the Covered Person s cover or date reinstatement whichever is latest except for accidental injuries.3. Care or treatment for which payment is not required or to the extent which is payable by any other takaful or indemnity covering the Participant and Disabilities arising out of duties of employment or profession that is covered under a Workman s Compensation Insurance Contract.4. Plastic/Cosmetic surgery, circumcision, eye examination, glasses and refraction or surgical correction of nearsightedness (Radial Keratotomy or Lasik) and the use or acquisition of external prosthetic appliances or devices such as artificial limbs, hearing aids, implanted pacemakers and prescriptions thereof.5. Dental conditions including dental treatment or oral surgery except as necessitated by Accidental injuries to sound natural teeth occurring wholly during the Period of Takaful.6. Private nursing, rest cures or sanitaria care, illegal drugs, intoxication, sterilization, venereal disease and its sequelae, AIDS (Acquired Immune Deficiency Syndrome) or ARC (AIDS Related Complex) and HIV related diseases, and any communicable diseases required quarantine by law.7. Any treatment or surgical operation for congenital abnormalities or deformities including hereditary conditions.8. Pregnancy, child birth (including surgical delivery), miscarriage, abortion and prenatal or postnatal care and surgical, mechanical or chemical contraceptive methods of birth control or treatment pertaining to infertility. Erectile dysfunction and tests or treatment related to impotence or sterilization.9. Psychotic mental or nervous disorders (including any neuroses and their physiological or psychosomatic manifestations).10. Hospitalisation primarily for investigatory purposes, diagnosis, X-ray examination, general physical or medical examinations, not incidental to treatment or diagnosis of a covered Disability or any treatment which is not Medically Necessary and any preventive treatments, preventive medicines or examinations carried out by a Physician, and treatments specifically for weight reduction or gain.11 Costs/ expenses of services of a non-medical nature, such as television, telephones, telex services, radios or similar facilities, admission kit/ pack and other ineligible non-medical items.12. Sickness or injury arising from racing of any kind (except foot racing), hazardous sports such as but not limited to skydiving, water skiing, underwater activities requiring breathing apparatus, winter sports, professional sports and illegal activities.13. Suicide, attempted suicide or intentionally self-inflicted injury while sane or insane.14. Private flying other than as a fare-paying passenger in any commercial scheduled airlines licensed to carry passengers over established routes.15. War or any act of war, declared or undeclared, criminal or terrorist activities, active duty in any armed forces, direct participation in strikes, riots and civil commotion or insurrection.16. Ionising radiation or contamination by radioactivity from any nuclear fuel or nuclear waste from process of nuclear fission or from any nuclear weapons material.17. Expenses incurred for donation of any body organ by a Covered Person and costs of acquisition of the organ including all costs incurred by the donor during organ transplant and its complications.18. Expenses Incurred for sex changes.19. Investigation, and treatment of sleep and snoring disorders, hormone replacement therapy and alternative therapy such as treatment, medical service or supplies, including but not limited to chiropractic services, acupuncture, acupressure, reflexology, bonesetting, herbalist treatment, massage or aroma therapy or other alternative treatment. 8
  9. 9. SPECIFIC CONDITIONS FOR SECTION A1. CONVERSION CERTIFICATES (applicable only if specified in the Certificate Schedule) If the Eligible Benefits provided under this Certificate shall have been converted from an existing coverage of an Inner Limits to an As Charged/Full Reimbursement coverage, and if such Participant shall have been afflicted with a Disability prior or at the time the Benefits were converted, the benefits payable in respect of the Disability shall be in accordance with the Schedule of Benefits prior to the date the Eligible Benefits were converted.2. FULL REIMBURSEMENT IN A GOVERNMENT HOSPITAL Charges for eligible medical expenses are covered in full for treatment in a Malaysian Government Hospital for each Illness or Injury, provided the claimant does not transfer from or to a private hospital for treatment and the room and board charge is not greater than that provided under the chosen Plan applicable to the claimant.3. OVERSEAS TREATMENT If the Covered Person seeks treatment overseas, benefits in respect of the treatment shall be covered subject to the exclusions, limitations and conditions specified in this Certificate and all benefits will be payable based on the official exchange rate ruling on the last day of the Period of Confinement and shall exclude the cost of transport to the place of treatment provided; (a) a Covered Person traveling abroad for a reason other than for medical treatment, needs to be confined to a Hospital outside Malaysia as a consequence of a Medical Emergency. (b) a Covered Person upon recommendation of a Physician and has to be transferred to a Hospital outside Malaysia because the specialised nature of the treatment, aid, information or decision required can neither be rendered nor furnished nor taken in Malaysia. Overseas treatment of a disease, sickness or injury which is diagnosed in Malaysia and non-emergency or chronic conditions where treatment can reasonably be postponed until return to Malaysia are excluded.4. REIMBURSEMENT OF SERVICE TAX Notwithstanding anything contained herein to the contrary, the certificate is extended to cover reimbursement of Government Service Tax payable in respect of treatment received for illnesses or conditions covered under the certificate. Such expenses shall be payable under Hospital Services and Supplies.5. RESIDENCE OVERSEAS No benefit whatsoever shall be payable for any medical treatment received by the Covered Person outside Malaysia, if the Covered Person resides or travels Outside Malaysia for more than ninety (90) consecutive days.6. TAKE-OVER CERTIFICATES (applicable only if specified in the Certificate Schedule) If this certificate shall have commenced immediately upon termination of a preceding Certificate and if a Covered Person shall have been afflicted with a medical disability prior or at the time this Certificate started (and benefits under the preceding Certificate would have been available to him), such Covered Person shall continue to be covered for the existing disability, but not to exceed the limits of the previous certificate on condition the Company has secured a copy of the preceding Certificate.7. UPGRADED CERTIFICATES (applicable only if specified in the Certificate Schedule) If the Eligible Benefits to any Covered Person under the terms of this Certificate be increased while it is in force or at the time of Renewal or replacement and if such Covered Person shall have been afflicted with a Disability prior or at the time the Benefits were increased, the Limits of Benefits payable in respect of such Disability shall not exceed the Limit of Benefits prior to the date the Benefits were upgraded.8. UPGRADED ROOM AND BOARD CO-PAYMENT If the Covered Person is hospitalised at a published Room & Board rate which is higher than his/ her eligible benefit, the Covered Person shall bear 20% of the other eligible benefits described in the Schedule of Benefits.9. WAITING PERIOD Eligibility for benefits starts thirty (30) days after the Participant has been included in the Certificate, except for a covered Accident occurring after the effective date of coverage. 9
  10. 10. SECTION B PERSONAL ACCIDENT BENEFITS DEFINITIONS1. ACCIDENTAL DEATH & PERMANENT DISABLEMENT Accidental death and permanent disablement shall mean a sudden, unintentional, unexpected, unusual and specific event that occurs at an identifiable time and place which shall, independently of any other cause, be the sole cause of bodily injury. The Company shall pay the Sum Covered specified in the Schedule of Benefits if death occurs within 365 days from the date of accident. If the Covered Person becomes permanently disabled within 365 days from the date of accident, the Company shall pay a percentage of the Sum Covered as specified in the Scale of Compensation for Permanent Disablement. If death occurs within 365 days from the date of accident following permanent disablement, the aggregate amount payable under all sections of the certificate shall not exceed the Sum Covered on death. SCALE OF COMPENSATION FOR PERMANENT DISABLEMENT Result Description % of Sum Covered 1. Total and permanent disablement from following any employment or occupation 100% 2. Total and permanent loss of all sight in one or both eyes 100% 3. Total loss by physical severance or total and permanent loss of use of:- (a) one or both hands at wrist 100% (b) arm at shoulder 100% (c) arm between shoulder and elbow 100% (d) arm at or below elbow 100% (e) leg at hip 100% (f) leg between knee and hip 100% (g) leg at or below knee 100% 4. Total and permanent loss of:- (a) sight in one eye, except perception of light 50% (b) lens of one eye 50% 5. Total and permanent loss of:- (a) hearing in both ears 75% (b) hearing in one ear 15% 6. Total and permanent loss of speech 50% 7. Total loss by physical severance or total and permanent loss of use of:- (a) thumb & 4 fingers of one hand 50% (b) 4 fingers of one hand 40% (c) thumb - 2 phalanges 25% - 1 phalanx 10% (d) index finger - 3 phalanges 15% - 2 phalanges 8% - 1 phalanx 4% (e) middle finger - 3 phalanges 10% 10
  11. 11. - 2 phalanges 4% - 1 phalanx 2% (f) ring finger - 3 phalanges 8% - 2 phalanges 4% - 1 phalanx 2% (g) little finger - 3 phalanges 6% - 2 phalanges 4% - 1 phalanx 2% (h) metacarpals - first & second (additional) 3% - third, fourth or fifth (additional) 2% (i) all toes of one foot 18% (j) great toe - 2 phalanges 6% - 1 phalanx 3% (k) any other toe 3% Where the injury is not specified, the Company reserves the right to adopt a percentage of disablement which in its opinion is not inconsistent with the provisions of the above Scale of Compensation. Total and permanent loss shall include total and permanent loss of use.2. EXTENSIONS a) EXPOSURE If following an accident the Covered Person is unavoidably exposed to the natural elements and as result of such exposures suffers an injury as specified in the Certificate Schedule, such injury shall be considered as constituting a claim but only in respect of death or permanent disablement. b) DISAPPEARANCE Notwithstanding anything contained herein to the contrary, if the body of the Covered Person has not been found within a year after the date of disappearance following an accident, the Company may in its absolute discretion upon being satisfied on the evidence available accept that the death of the Covered Person has been established provided that if at any time after the payment has been made by the Company in settlement of a claim in such circumstances, the Covered Person is found to be living any sum so paid by the Company shall be refunded forthwith. c) STRIKE, RIOT AND CIVIL COMMOTION This Certificate is extended to cover the Covered Person as within defined directly or indirectly caused by Strike, Riot or Civil Commotion not amounting to the proportion of a popular uprising except in so far as the Covered Person himself is actively participating when this extension becomes null and void. d) MOTORCYCLING This Certificate is extended to cover the Covered Person as within mentioned resulting from the Covered Person engaging in motorcycling, provided always that this extension does not apply to any accidents arising out of motorcycle racing, pace-making, reliability trial or speed testing. 11
  12. 12. EXCLUSIONS FOR SECTION BThis Takaful shall not apply to any accident consequent upon or caused by or contributed by or arising from:-1. war, invasion, act of foreign enemy, hostilities or war-like operations (whether war be declared or not), civil war, mutiny, civil commotion assuming the proportions of or amounting to a popular rising, military rising, insurrection, rebellion, revolution, conspiracy, military or usurped power, or any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of any de jure or de facto Government or to the influencing of it by terrorism or violence.2. nuclear weapon materials, ionising materials or contamination by radioactivity from any nuclear waste from the combustion of nuclear fuel and for this exclusion combustion shall include self sustaining process of nuclear fusion.3. the Covered Person being in or upon or entering or descending from Aircraft of any kind or caused by or resulting from a descent or fall from such Aircraft whilst traveling as a pilot or a member of the aircrew.4. the Covered Person engaging in professional sports, speed contest, racing of any kind (other than on foot), hunting, mountaineering as a profession, water ski jumping, hang-gliding, under-water activities involving the use of breathing apparatus, or using wood-working machinery driven by mechanical power other than portable tools applied by hand.5. the Covered Person being affected (temporarily or otherwise) by drug or alcohol unless it can be established to the Company s satisfaction by the claimant that the alcohol or drug was not a factor contributing to the happening of the event.6. sickness or disease of any kind, pregnancy or childbirth or pre-existing physical defect or infirmity, insanity, suicide, or intentional self injury.7. provoked murder or assault.8. the Covered Person while committing or attempting to commit any unlawful act.9. Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) howsoever this syndrome has been acquired or may be named.10. the Covered Person who is actively involved in any of the following occupations or duties:- a) Police, army, military and law enforcement officers b) Aircraft testers, pilots and crew c) Divers, unless as a hobby d) Racing drivers e) Jockeys f) Persons engaged in professional sports activities g) Persons engaged in underground mining and tunneling h) Seamen and sea fishermen i) Oil rig workers j) Steeplejacks k) Stevedores l) Persons engaged in demolition of buildings m) Wood working machinist n) Fireman o) War Correspondents p) Explosive handlers q) Sawyer, timber, logging workers, drivers and attendants of timber lorries and winches 12
  13. 13. GENERAL CONDITIONS1. ALTERATIONS The Company reserves the right to amend the terms and provisions of this Certificate by giving a 30 day prior notice in writing by ordinary post to the Participant s last known address in the Company s records, and such amendment will be applicable from the next renewal of this Certificate. No alteration to this Certificate shall be valid unless Authorized by the Company and such approval is endorsed thereon. The Company should give 30 days prior written notice to the Participant according to the last recorded address for any alterations made.2. ARBITRATION All differences arising out of this Certificate shall be referred to an Arbitrator who shall be appointed in writing by the parties in difference. In the event they are unable to agree on who is to be the Arbitrator within one (1) month of being required in writing to do so, then both parties shall be entitled to appoint an Arbitrator each who shall proceed to hear the differences together with an Umpire to be appointed by both Arbitrators. However this is provided that any disclaimer of liability by the Company for any claim hereunder must be referred to an Arbitrator within twelve (12) calendar months from date of such disclaimer.3. CHANGE IN RISK The Covered Person shall give immediate notice in writing to the Company of any material change in his or her occupation, business, duties or pursuits and pay any additional contribution that may be required by the Company.4. CANCELLATION OF CERTIFICATE (applicable to yearly renewable Certificate only) This Certificate may be cancelled by the Participant at any time by giving a written notice to the Company, and provided that no claims have been made during the current Certificate year, the Participant shall be entitled to a refund of the contribution as follows:- Period Refund of Annual Contribution Not exceeding 15 days 90% (applicable to renewal only) Not exceeding 1 month 80% Not exceeding 2 months 70% Not exceeding 3 months 60% Not exceeding 4 months 50% Not exceeding 5 months 40% Not exceeding 6 months 30% Not exceeding 7 months 25% Not exceeding 8 months 20% Not exceeding 9 months 15% Not exceeding 10 months 10% Not exceeding 11 months 5% Exceeding 11 months No refund of Contribution5. CASH BEFORE COVER It is a fundamental and absolute special condition of this contract of takaful that the contribution due must be paid and received by the Company before takaful cover is effective.6. CERTIFICATION, INFORMATION AND EVIDENCE All certificates, information, medical reports and evidence as required by the Company shall be furnished at the expense of the Participant, and in such a form that the Company may require. In any event all notices which the Company shall require the Participant to give must be in writing and addressed to the Company. A Participant shall, at the Company s request and expense, submit to a medical examination whenever such is deemed necessary. 13
  14. 14. 7. CLAIM PROCEDURES (a) The Participant shall within thirty (30) days of a Disability that incurs claimable expenses give written notice to the Company stating full particulars of such event, including all original bills and receipts, and a full Physician s report stipulating the diagnosis of the condition treated and the date the Disability commenced in the Physician s opinion and the Physician s summary of the cost of treatment including medicines and services rendered. Failure to furnish such notice within the time allowed shall not invalidate any claim if it is shown not to have been reasonably possible to furnish such notice and that such notice was furnished as soon as was reasonably possible. (b) The Participant shall immediately procure and act on proper medical advice and the Company shall not be held liable in the event a treatment or service becomes necessary due to failure of the Participant to do so.8. CONDITION PRECEDENT TO LIABILITY The due observance and the fulfillment of the terms, provisions and conditions of this Certificate by the Covered Person and in so far as they relate to anything to be done or complied with by the Covered Person shall be conditions precedent to any liability of the Company.9. CONTRIBUTION If a Covered Person carries other takaful or insurance covering any illness or injury covered by this Certificate, the Company shall not be liable for a greater proportion of such illness or injury than the amount applicable hereto under this Certificate bears to the total amount of all valid takaful or insurance covering such illness or injury.10. PERIOD OF KHIYAR (RIGHT OF CANCELLATION) If this Certificate shall have been issued and for any reason whatsoever the Covered Person shall decide not to take up the Certificate, the Covered Person may return the Certificate to the Company for cancellation provided such request for cancellation is delivered by the Covered Person to the Company within fifteen (15) days from the date of delivery of the Certificate. The Covered Person is entitled to the return of the full contribution paid less deduction of medical expenses incurred by the Company in the issue of the Certificate.11. CURRENCY OF PAYMENT All payments under this Certificate shall be made in the legal currency of Malaysia. Should any payment be requested by the Participant to be payable in any other currency, then such amount shall be payable in the demand currency as may be purchased in Malaysia at the prevailing currency market rates on the date of the claim settlement.12. GOVERNING LAW This Certificate is issued under the laws of Malaysia and is subject and governed by the laws prevailing in Malaysia.13. GRACE PERIOD (only applicable to annual contribution) Notwithstanding the Cash Before Cover Condition, a Grace Period of fourteen (14) days following the expiry date shall be allowed to the Participant for the payment of any contributions after the first Certificate year. If any contribution is not paid in respect of this Certificate or any supplementary contracts before the end of the Grace Period, this Certificate and the relevant supplementary contracts shall be deemed as terminated at the expiry date of the Certificate. Even if payment is made during the Grace Period, any disability occurring during the period from the expiry date to the payment date shall not be payable.14. INCOMPLETE CLAIMS All claims must be submitted to the Company within thirty (30) days of completion of the events for which the claim is being made. Claims are not deemed complete and Eligible Benefits are not payable unless all bills for such claims have been submitted and agreed upon by the Company. Only actual costs incurred shall be considered for reimbursement. Any variation or waiver of the foregoing shall be at the Company s sole discretion.15. LEGAL PROCEEDINGS No action at law or in equity shall be brought to recover on this Certificate prior to expiration of sixty (60) days after written proof of loss has been furnished in accordance with the requirements of this Certificate. If the Covered Person shall fail to supply the requisite proof of loss as stipulated by the terms, provisions and conditions of the Certificate, the Covered Person may, within a grace period of one calendar year from the time that the written proof of loss to be furnished, submit the relevant proof of loss to the Company with cogent reason(s) for the failure to comply with the Certificate terms, provisions and conditions. The acceptance of such proof of loss shall be at the sole and entire discretion of the Company. After such grace period has expired, the Company will not accept, for any reason whatsoever, such written proof of loss. 14
  15. 15. 16. MISREPRESENTATION / FRAUD If the proposal or declaration of the Covered Person is untrue in any respect or if any material fact affecting the risk be incorrectly stated herein or omitted therefrom, or if this takaful, or any renewal thereof shall have been obtained through any misstatement, misrepresentation or suppression, or if any claim made shall be fraudulent or exaggerated, or if any false declaration or statement shall be made in support thereof, then in any of these cases, this Certificate shall be void.17. MISSTATEMENT OF AGE If the age of the Covered Person has been misstated and the contribution paid as a result thereof is insufficient, any claim payable under this Certificate shall be prorated based on the ratio of the actual contribution paid to the correct contribution which should have been charged for the year. Any excess contribution which may have been paid as a result of such misstatement of age shall be refunded without interest. If at the correct age the Covered Person would not have been eligible for cover under this Certificate, no benefit shall be payable.18. NOTICE Every notice or communication to the Company shall be in writing and sent to the Company. No alterations in the terms of this Certificate or any endorsement thereon will be held valid unless the same is signed or initialed by an authorised representative of the Company.19. OFF-DUTY CLAUSE It is hereby agreed and understood that notwithstanding anything contained herein to the contrary, the exclusion regarding the occupations/duties will only apply whilst at work or whilst engaged in work-related activities including traveling to and from the place of work.20. OWNERSHIP OF CERTIFICATE Unless otherwise expressly provided for by Endorsement in the Certificate, the Company shall be entitled to treat the Participant as the absolute owner of the Certificate. The Company shall not be bound to recognise any equitable or other claim to or interest in the Certificate, and the receipt of the Certificate or a Benefit by the Participant (or by his legal or authorized representative) alone shall be an effective discharge of all obligations and liabilities of the Company. The Participant shall be deemed to be responsible Principal or Agent of the Covered Persons covered under this Certificate.21. PORTFOLIO WITHDRAWAL CONDITION The Company reserves the right to cancel the portfolio as a whole if it decides to discontinue underwriting this takaful product. Cancellation of the portfolio as a whole shall be given by a thirty (30) day prior written notice to the Participant and the Company will run off all policies to expiry of the period of cover within the portfolio.22. SUBROGATION If the Company shall become liable for any payment under this Certificate, the Company shall be subrogated to the extent of such payment to all the rights and remedies of the Covered Person against any party and shall be entitled at its own expense to sue in the name of the Covered Person. The Covered Person shall give or cause to be given to the Company all such assistance in his/ her power as the Company shall require to secure the rights and remedies and at the Company s request shall execute or cause to be executed all documents necessary to enable the Company to effectively to bring suit in the name of the Covered Person.23. TERMINATION OF COVERED PERSON AND COMPANY LIABILITY A Covered Person shall cease to be a Covered Person on: (a) the Certificate anniversary following the attainment of the 80th birthday and for children on the Certificate th rd anniversary following the attainment of the 19 birthday or the 23 birthday for those registered as full time students at a recognised educational institution. (b) the date of termination of the Certificate or any person s coverage. In any case, the Company s liability shall cease with the date of termination of the Certificate or any person s coverage.24. CONTRIBUTION ALLOCATION Payment of the takaful Contribution as shown in the Schedule paid by the Participant shall be placed in the General Risk Investment Account (GRIA) where the Company will manage the fund according to the Wakalah Principle as defined by the Company and in accordance with Shariah principles. A single drip from the GRIA will be made towards the Expense Fund, Risk Fund and Special Fund at inception, for the Wakalah Fee and Tabarru charges respectively. 15
  16. 16. 25. SURPLUS At each financial year-end, the Actuary will assess the surplus position of the Risk Fund. The company shall charge a Surplus Administration Charge (SAC) of up to 50% of the gross surplus arising from the Risk Fund at the end of the financial year. Any net surplus arising (after the SAC) shall be apportioned between the Participant and the Special Fund. The apportionment for Participant shall not be less than provision for the SAC. If the amount due to Participant is less than RM10 per Certificate, the amount shall be transferred to the Special Fund. Any deficit in the Risk Fund will first be paid from the Special Fund. If such fund is not sufficient, it would be met through an interest free loan (Qard) from the Shareholders Fund. Such loan would be a first charge against the future surplus arising from the Risk Fund.26. MODAL CONTRIBUTION CLAUSE Notwithstanding anything contained herein to the contrary, it is hereby declared and agreed that the contribution is payable on a modal frequency and is subject to the modal contribution factor determined by the Company. It is further declared and agreed that in consequence of the modal payment of contribution, the Certificate is subject to the following:- (a) Grace Period Condition is deemed to be deleted. (b) No refund of contribution will be allowed under the monthly contribution payment mode if the Certificate is cancelled by the Participant under the Cancellation of Certificate Condition. Subject otherwise to the provisions, terms, exclusions and conditions of this Certificate.IMPORTANT NOTICEWe care about the service that we provide for our customers, and our staff makes every effort to maintain as high a standard aspossible. In the event that we do not meet your expectations and you are dissatisfied in some way, we would like to know andwould ask you:Step 1: To speak first to the intermediary who arranged the Certificate for you.Step 2: If you remain dissatisfied, ask to speak to our branch manager. Our manager will give personal attention to your enquiry and point you in the right direction if you wish to take the matter further.Step 3: If the matter is not resolved, write to our Customer Relationship Management, Takaful Ikhlas Sdn Bhd, IKHLAS Point, Tower 11A, Avenue 5, Bangsar South, No. 8 Jalan Kerinchi, 59200 Kuala Lumpur, who will make sure that your case is examined thoroughly. In the event that you are still not satisfied, you must address your complaint to the following for investigation into unfair market practices by Takaful Operators / Insurers. Financial Mediation Bureau Pengarah Level 25, Jabatan Komunikasi Korporat Dataran Kewangan Darul Takaful Bank Negara Malaysia No 4, Jalan Sultan Sulaiman Peti Surat 10922 50000 Kuala Lumpur. 50929 Kuala Lumpur Tel : 03-2272 2811 Tel : 03-2698 8044 Fax : 03-2274 5752 Fax : 03-2693 6919 E-mail address : enquiry@fmb.org.my 16
  17. 17. CLAUSES/ENDORSEMENTS/PERILS & WARRANTIESThe following perils, clauses, endorsements and/or warranties only apply to this certificate when specifically mentioned in theSchedule and subject otherwise to the Terms of this Certificate.MD01 REASONABLE AND CUSTOMARY CHARGES It is hereby declared and agreed that for treatment in Malaysia, the Malaysian Medical Association Schedule of Fees th (4 Edition) shall be used for determining reasonable and customary charges.MD02 EXCLUSION CLAUSE The Company shall not be liable for any claims arising directly or indirectly from treatment pertaining to the disability in respect of Participant, as stated under Exclusions for Section AMD03 AUTOMATIC TERMINATION OF COVER (foreigner only) Notwithstanding anything contained herein to the contrary, it is hereby declared and agreed that the insurance coverage shall automatically terminate upon expiry of work permit or when the Participant Person cease to reside in Malaysia. No contribution will be refunded.MD04 LOCAL TREATMENT CLAUSE (foreigner only) Notwithstanding anything contained herein to the contrary, if the Participant Person is a non-Malaysian, the coverage and benefits provided shall be restricted to treatment in Malaysia only.MD05 TREATMENT IN SINGAPORE AND BRUNEI DARUSSALAM CLAUSE It is hereby declared and agreed that in consideration of a contribution loading of 20%, the Certificate is hereby extended to cover treatment in Singapore and Brunei Darussalam. It is further declared and agreed that the eligible claim shall be paid on the basis of One Ringgit Malaysia to One Singapore Dollar or One Brunei Dollar respectively. For the purpose of determining the applicable Co-Payment for Upgraded Room, the Room Rate shall also be considered on the basis of One Ringgit Malaysia to One Singapore Dollar or One Brunei Dollar respectively. It is also declared and agreed that in consideration of this extension, the Residence Overseas Clause restricting travel overseas to ninety (90) consecutive days shall not apply to Singapore and Brunei Darussalam. Notwithstanding anything contained herein to the contrary, if the Covered Person is a Singaporean/Bruneian, the coverage and benefits provided shall be restricted in Malaysia, Singapore and Brunei only.MD06 TAKE-OVER CERTIFICATES If this Certificate shall have commenced immediately upon termination of a preceding Certificate and if a Covered Person shall have been afflicted with a medical disability prior or at the time this Certificate started (and benefits under the preceding Certificate would have been available to him), such Covered Person shall continue to be covered for the existing disability, but not to exceed the limits of the previous Certificate on condition the Company has secured a copy of the preceding Certificate.MD07 CONVERSION CERTIFICATES If the Eligible Benefits provided under this Certificate shall have been Converted from an existing coverage of an Inner Limits to an As Charged/Full Reimbursement coverage, and if such Covered Person shall have been afflicted with a Disability prior or at the time the Benefits were converted, the benefits payable in respect of the Disability shall be in accordance with the Schedule of Benefits prior to the date the Eligible Benefits were converted.MD08 UPGRADED CERTIFICATES If the Eligible Benefits to any Covered Person under the terms of this Certificate be increased while it is in force or at the time of renewal or replacement and if such Covered Person shall have been afflicted with a Disability prior or at the time the Benefits were increased, the Limits of Benefit payable in respect of such Disability shall not exceed the Limit of Benefits prior to the date the Benefits were upgraded. 17
  18. 18. IKHLAS PHM VIP MEDICALTAKAFUL (Perlindungan Penghospitalan dan Pembedahan Takaful)DIMANA Peserta yang dinamakan di dalam Jadual Sijil telah memohon kepada Takaful Ikhlas Sdn Bhd (selepas daripada inidipanggil Syarikat ) ataupun takaful sepertimana dinyatakan di dalam ini dan telah membayar atau bersetuju membayarsumbangan yang dinyatakan di dalam Jadual Sijil sebagai pertimbangan bagi takaful yang terkandung didalamnya.DENGAN INI SIJIL INI MEMPERAKUKAN bahawa jika Orang Yang Dilindungi dimasukkan ke hospital untuk rawatan ataudirawat kerana pembedahan bagi kes harian semasa Tempoh Takaful yang dinyatakan di dalam Jadual Sijil, Syarikat akanmembayar kepada Peserta atau wakil sah peribadinya jumlah atau jumlah dinyatakan di dalam Jadual Sijil. Pembayaranadalah tertakluk kepada caj-caj munasabah dan yang diamalkan dan hanya akan dibuat sebaik sahaja bukti-bukti perbelanjaanyang ditanggung telah diterima dan diluluskan.SIJIL INI adalah tertakluk kepada peruntukan syarat dan pengecualian seperti yang terkandung di dalam ini atau sebagaimanayang mungkin disahkan selepas daripada ini. JADUAL MANFAAT KETERANGAN MANFAAT SEKSYEN A MANFAAT PERBELANJAAN HOSPITAL PVM 1(a) PVM 2(a) 1. Bilik Hospital Serta Makan, maksimum harian sehingga 365 hari 500 350 2. Unit Kawalan Rapi, maksimum harian sehingga 365 hari 3. Bekalan & Perkhidmatan Hospital 4. Khidmat rundingan & diagnosa pra pembedahan, dalam tempoh 31 hari sebelum pembedahan 5. Pembayaran Pembedahan (termasuk Pembayaran Pakar Bius dan Bilik Bedah) 6. Perundingan Pakar & Ujian Diagnostik Pra- Hospital, dalam tempoh 31 hari sebelum penghospitalan Seperti dikenakan (tertakluk kepada caj- caj munasabah dan yang diamalkan) 7. Lawatan Pakar Di Dalam Hospital, maksimum harian sehingga 365 hari 8. Rawatan Selepas Penghospitalan, dalam tempoh 60 hari daripada tarikh keluar daripada hospital 9. Bayaran Ambulans 10. Rawatan Kecemasan Kemalangan Bagi Pesakit Luar, setiap kemalangan temasuk rawatan susulan sehingga 31 hari 11. Rawatan Kecemasan Pergigian, setiap kemalangan termasuk rawatan susulan sehingga 31 hari 12. Manfaat Harian Penjagaan Anak, maksimum harian sehingga 365 Dilindungi Dilindungi hari 13. Bayaran Laporan Perubatan, setiap kehilangan upaya 100 100 14. Cukai Perkhidmatan Kerajaan Dilindungi Dilindungi 15. Perbelanjaan Pengkebumian 5,000 3,000 16. Manfaat Tunai Penghospitalan, sehingga 60 hari (dibayar daripada Dilindungi Dilindungi hari ketiga dan berikutnya) 17. Rawatan Pesakit Luar Bagi Kanser, setahun 60,000 36,000 18. Rawatan Pesakit Luar bagi Dialisis Buah Pinggang, setahun 60,000 36,000 Had Setiap Kehilangan Upaya 200,000 150,000 Had Tahunan Keseluruhan 600,000 450,000 HAD SEUMUR HIDUP 600,000 450,000 SEKSYEN B- MANFAAT KEMALANGAN DIRI Kematian Akibat Kemalangan & Keilatan Kekal 200,000 150,000 18
  19. 19. PERUNTUKAN-PERUNTUKAN AM1. ORANG YANG LAYAK Orang yang layak untuk dilindungi di bawah Sijil ini adalah: (a) Peserta yang berumur di bawah 80 tahun; (b) Suami/isteri Peserta yang sah berumur di bawah 80 tahun, kecuali berpisah secara sah daripada Peserta mengikut perundangan, dan (c) Anak Peserta yang telah mencapai umur tiga puluh (30) hari dan belum berkahwin, yang bergantung dari segi kewangan pada Peserta dan berumur kurang daripada sembilan belas (19) tahun atau hingga dua puluh tiga (23) tahun bagi mereka yang didaftarkan sebagai pelajar sepenuh masa di institusi pengajian yang diiktiraf.2. TEMPOH PERLINDUNGAN DAN PEMBAHARUAN Sijil ini akan berkuatkuasa seperti tarikh yang dinyatakan di dalam Jadual. Ulang Tahun Sijil adalah satu tahun selepas tarikh berkuatkuasa dan setiap tahun berikutnya. Pada setiap ulang tahun tersebut, Sijil ini boleh diperbaharui pada kadar sumbangan yang berkuatkuasa pada masa itu dan seperti yang dimaklumkan oleh Syarikat. Sijil ini boleh diperbaharui mengikut pilihan Peserta tertakluk kepada terma, syarat dan penamatan pada setiap tarikh ulang tahun Sijil. Sumbangan pembaharuan yang dibayar tidak dijamin dan Syarikat berhak menyemak semula kadar sumbangan yang digunapakai untuk setiap Peserta pada masa pembaharuan itu. Pada masa pembaharuan, terma dan syarat perlindungan tidak boleh dipinda, kecuali apabila hilang upaya tertentu telah mencapai had maksimum bagi setiap hilang upaya. Dalam keadaan itu, Syarikat berhak secara khusus mengeluarkan hilang upaya itu daripada peruntukan Sijil ini. Sijil ini boleh diperbaharui mengikut pilihan Peserta sehinggalah berlaku mana-mana daripada yang berikut: (a) tiada pembayaran sumbangan atau sumbangan tidak dibuat pada masanya (b) penipuan atau salah-nyata bahan fakta penting semasa membuat permohonan (c) Sijil dibatalkan atas permintaan Peserta (d) jumlah tuntutan Sijil telah mencapai had seumur hidup ditetapkan dan/atau berlaku kematian Orang Yang Dilindungi (e) Orang Yang Dilindungi tidak lagi layak menjadi tanggungan berdasarkan takrif Sijil (f) Orang Yang Dilindungi mencapai had umur perlindungan ditetapkan (g) Penamatan perlindungan bagi semua Sijil dalam pasaran tertentu dan Syarikat menarik-balik Sijil ini sepenuhnya daripada pasaran berdasarkan Syarat Penarikan-Balik Portfolio. Syarikat akan memberi 30 hari notis bertulis kepada Peserta sekiranya berlaku penyemakan semula dalam sumbangan atau penarikan-balik portfolio.3. WILAYAH GEOGRAFI Semua Manfaat yang ditawarkan di dalam Sijil ini adalah digunapakai di seluruh sedunia, dua puluh-empat (24) jam sehari.4. WARIS PESERTA (PEMEGANG SIJIL BERIKUTNYA) (a) Sekiranya berlaku kematian kepada Peserta semasa Sijil ini berkuatkuasa, suami/isteri sah Peserta secara automatik akan menjadi Peserta setelah menandatangani akad baru dan semua rujukan di bawah Sijil ini terhadap Peserta akan selepas daripada ini bermaksud suami/isteri tersebut. (b) Bila Orang Yang Dilindungi tidak lagi layak dikira sebagai anak tanggungan, Orang Yang Dilindungi ini boleh terus membaharui Sijil di atas namanya sendiri sebagai Peserta dan semua rujukan di dalam Sijilnya ke atas Peserta selepas daripada ini akan bermaksud Orang Yang Dilindungi tersebut. 19
  20. 20. SEKSYEN A MANFAAT PERBELANJAAN HOSPITAL DEFINISI1. KEMALANGAN bermaksud kejadian yang berlaku secara tiba-tiba, tidak disengajakan, tidak dijangka, luar biasa dan kejadian tertentu pada masa dan di tempat yang dikenal pasti, yang hendaklah, tanpa bergantung pada apa-apa sebab lain, menjadi satu-satunya sebab bagi kecederaan anggota badan.2. MANA-MANA SATU HILANG UPAYA hendaklah bermaksud mana-mana hilang upaya yang timbul daripada sebab yang sama termasuk mana-mana dan semua komplikasinya kecuali jika Orang yang Dilindungi pulih sepenuhnya dan tidak perlu menjalani apa-apa rawatan lanjut (termasuk dadah, ubat, diet khas atau suntikan atau nasihat tentang keadaannya) bagi hilang upaya itu selama sekurang-kurangnya sembilan puluh (90) hari selepas tarikh terakhir dibenarkan keluar hospital dan hilang upaya berikutnya daripada sebab yang sama akan dikira sepertimana ianya adalah hilang upaya baru.3. SEPERTI CAJ DIKENAKAN merujuk kepada caj-caj sebenar yang dkenakan bagi penjagaan perubatan munasabah, mustahak dan biasa diamalkan seperti yang dinyatakan di dalam rawatan bagi perlindungan hilang upaya.4. ANAK bermaksud mana-mana orang yang telah mencapai umur tiga puluh (30) hari dan tidak berkahwin, yang bergantung dari segi kewangan pada Peserta dan berumur kurang daripada sembilan belas (19) tahun atau hingga dua puluh tiga (23) tahun bagi mereka yang didaftarkan sebagai pelajar sepenuh masa di institusi pengajian yang diiktiraf.5. PENYAKIT KONGENITAL bermaksud apa-apa keabnormalan perubatan atau fizikal yang wujud sejak lahir, dan juga keabnormalan fizikal neo-natal yang berkembang dalam tempoh enam (6) bulan dari tarikh kelahiran. Ini termasuk semua jenis hernia dan epilepsi kecuali disebabkan oleh trauma yang berlaku selepas tarikh Peserta dilindungi secara berterusan di bawah Sijil ini.6. DOKTOR atau PAKAR PERUBATAN atau PAKAR BEDAH akan bermaksud pengamal perubatan yang didaftarkan, berkelayakan dan dilesenkan untuk mengamalkan perubatan cara barat dan memberikan khidmat rawatan tersebut mengikut skop perlesenan dan latihannya di kawasan geografi perkhidmatannya, tetapi tidak termasuk doktor, pakar perubatan atau pakar bedah yang merupakan Peserta sendiri.7. DOKTOR GIGI akan bermaksud orang yang berlesen atau berdaftar sewajarnya untuk mengamalkan khidmat pergigian dalam kawasan geografi yang menyediakan khidmat, tetapi tidak termasuk pakar perubatan atau pakar bedah yang merupakan Peserta itu sendiri.8. TANGGUNGAN akan bermaksud mana-mana orang berikut: (a) suami/isteri yang berkahwin secara sah (b) anak yang tidak berkahwin yang umurnya melebihi tiga puluh (30) hari tetapi di bawah sembilan belas (19) tahun atau dua puluh tiga (23) tahun bagi yang masih menjadi pelajar sepenuh masa di pusat pengajian tinggi, dan yang tidak mempunyai pekerjaan bergaji9. PEMBEDAHAN HARIAN Bermaksud pesakit yang perlu menggunakan kemudahan pemulihan untuk prosedur pembedahan yang dirancang terlebih dahulu di hospital/klinik pakar (tetapi bukan untuk bermalam).10. HILANG UPAYA bermaksud Sakit, Wabak, Penyakit atau semua Kecederaan yang timbul daripada satu atau beberapa sebab yang berterusan.11. PERBELANJAAN LAYAK bermaksud belanja yang Perlu Dari Segi Perubatan yang ditanggung disebabkan oleh Hilang Upaya yang dilindungi tetapi tidak melebihi had manfaat dalam jadual.12. HOSPITAL bermaksud hanya pertubuhan yang ditubuhkan dan didaftarkan sewajarnya sebagai hospital untuk jagaan dan rawatan orang yang sakit dan cedera sebagai pesakit atas katil berbayar, dan yang:- (a) mempunyai kemudahan bagi diagnosis dan pembedahan utama (b) menyediakan khidmat kejururawatan dua puluh empat (24) jam sehari oleh jururawat berdaftar dan siswazah, (c) di bawah penyeliaan Pakar Perubatan, dan (d) bukan klinik, tempat untuk orang ketagih alkohol atau dadah, pusat jagaan atau rumah pemulihan atau rumah orang tua atau pertubuhan yang serupa. 20
  21. 21. 13. PENGHOSPITALAN bermaksud dimasukkan ke Hospital sebagai pesakit dalaman yang berdaftar untuk rawatan yang Perlu Dari Segi Perubatan bagi Hilang Upaya yang dilindungi apabila disyorkan oleh pakar perubatan. Pesakit tidak boleh dianggap sebagai pesakit dalaman jika pesakit tidak tinggal di hospital secara fizikal sepanjang tempoh dimasukkan ke hospital.14. UNIT RAWATAN RAPI bermaksud satu bahagian di Hospital yang dinamakan sebagai Unit Rawatan Rapi oleh Hospital, dan yang diselenggara dua puluh empat (24) jam hanya untuk rawatan bagi pesakit dalam keadaan kritikal dan dilengkapi khidmat jagaan dan perubatan khas yang tidak disediakan di mana-mana bahagian lain Hospital itu.15. KECEDERAAN bermaksud kecederaan anggota badan yang semata-mata disebabkan oleh Kemalangan.16. ORANG YANG DILINDUNGI bermaksud orang yang dinyatakan dalam Jadual Sijil, termasuk Tanggungannya (jika berkenaan).17. HAD SEUMUR HIDUP akan bermaksud jumlah maksimum yang dibayar ke atas Orang Yang Dilindungi bagi seumur hidupnya. Sebaik sahaja had seumur hidup telah dicapai, Sijil secara automatiknya akan ditamatkan. Di mana dinyatakan di dalam Sijil, had seumur hidup adalah terpakai.18. HOSPITAL KERAJAAN MALAYSIA bermaksud hospital yang bayaran perkhidmatannya tertakluk kepada Akta Fee 1951, Perintah Fee (Perubatan) 1982 dan/atau pindaan berikutnya jika ada.19. PERLU DARI SEGI PERUBATAN bermaksud khidmat perubatan yang: (a) selaras dengan diagnosis dan rawatan perubatan yang diamalkan bagi Hilang Upaya yang dilindungi, dan (b) menurut piawai amalan perubatan yang baik, selaras dengan piawai semasa bagi rawatan perubatan profesional, dan juga dengan manfaat kesihatan yang sah terbukti, dan (c) bukan untuk kemudahan Peserta atau Pakar Perubatan, dan tidak dapat diperoleh sewajarnya di luar hospital (jika dimasukkan ke wad sebagai pesakit dalaman), dan (d) bukan berbentuk eksperimen, penyelidikan atau kajian, pencegahan atau penyaringan, dan (e) bayarannya berpatutan, munasabah dan biasa diamalkan bagi Hilang Upaya itu.20. PESAKIT LUAR bermaksud Orang yang Dilindungi yang menerima jagaan atau rawatan perubatan tanpa dimasukkan ke hospital dan termasuk rawatan di pusat Rawatan Harian.21. HAD TAHUNAN KESELURUHAN Manfaat yang dibayar bagi perbelanjaan yang dikenakan untuk rawatan yang diberikan kepada Orang yang Dilindungi dalam tempoh takaful hendaklah dihadkan mengikut Had Tahunan Keseluruhan seperti yang dinyatakan dalam Jadual Manfaat tanpa mengira jenis hilang upaya. Jika Had Tahunan Keseluruhan telah dibayar, maka semua perlindungan bagi Orang yang Dilindungi di bawah Sijil ini hendaklah dihentikan bayarannya serta-merta bagi baki tahun Sijil tersebut.22. PESERTA bermaksud orang atau badan korporat yang kepadanya Sijil dikeluarkan bagi melindungi orang yang secara khusus dikenalpasti sebagai Orang yang Dilindungi dalam Sijil ini.23. TAHUN SIJIL bermaksud tempoh satu tahun termasuk tarikh mula kuatkuasa Takaful dan sebaik sahaja selepas tarikh itu, atau tempoh satu tahun selepas Sijil Pembaharuan atau Sijil Baru.24. PENYAKIT SEDIA ADA bermaksud hilang upaya yang diketahui sewajarnya oleh Orang yang Dilindungi. Pemegang Sijil dianggap mengetahui sewajarnya keadaan sedia ada itu apabila:- (a) Orang yang Dilindungi telah atau sedang menerima rawatan; (b) nasihat perubatan, diagnosis, jagaan atau rawatan telah disyorkan; (c) gejala yang jelas dan tepat dapat atau telah dilihat dengan nyata; atau (d) kewujudannya dapat diperhatikan dengan jelas bagi orang yang munasabah yang mengalami keadaan itu.25. UBAT YANG DIPRESKRIPSIKAN bermaksud ubat yang diberikan oleh Pakar Perubatan, Ahli Farmasi Berdaftar atau Hospital dan yang dipreskripsikan oleh Pakar Perubatan atau Pakar bagi rawatan Hilang Upaya yang dilindungi.26. BAYARAN MUNASABAH DAN BIASA DIAMALKAN bermaksud bayaran rawatan perubatan yang perlu dari segi perubatan, yang dianggap munasabah dan biasa diamalkan selagi bayaran itu tidak melebihi had biasa bayaran yang dibuat oleh pihak lain yang sama kedudukannya di tempat bayaran itu dikenakan, apabila memberikan rawatan, khidmat atau bekalan seumpamanya atau yang serupa kepada individu dengan jantina yang sama dan kategori umur yang sama untuk sakit, wabak atau kecederaan serta selaras dengan piawaian dan amalan perubatan yang diterima dan tidak boleh diabaikan tanpa menjejaskan keadaan perubatan Orang yang Dilindungi.27. SIJIL PEMBAHARUAN ATAU SIJIL BARU bermaksud Sijil yang telah dibaharui tanpa apa-apa tempoh luput sebaik sahaja tamatnya tempoh setelah Sijil sebelumnya dengan kandungan yang sama. 21
  22. 22. 28. SAKIT, WABAK ATAU PENYAKIT bermaksud keadaan fizikal yang ditunjukkan dari segi patologi berbeza daripada keadaan kesihatan yang normal.29. PAKAR bermaksud pengamal perubatan atau pergigian yang berdaftar dan berlesen sewajarnya di kawasan geografi yang khidmat tersebut diberikan, dan yang diklasifikasikan oleh pihak berkuasa kesihatan yang berkenaan sebagai orang yang mempunyai kepakaran yang tinggi dan khusus dalam bidang perubatan atau pergigian yang tertentu, tetapi tidak termasuk pakar perubatan atau pakar bedah yang merupakan Peserta itu sendiri.30. PEMBEDAHAN bermaksud mana-mana prosedur perubatan yang berikut: (a) Untuk menginsisi (incise), mengeksisi (excise) atau mengeletrokauteri (electrocauterize) mana-mana bahagian organ atau badan kecuali untuk khidmat pergigian. (b) Untuk membaiki, mengubah atau membentuk semula mana-mana bahagian organ atau badan. (c) Untuk mengurangkan fraktur atau dislokasi melalui manipulasi. (d) Penggunaan endoskopi untuk mengeluarkan batu atau objek dari larinks, bronkus, trakea, esophagus, perut, usus, pundi kencing, atau uretra. KETERANGAN MANFAAT-MANFAATSEKSYEN A1 BILIK HOSPITAL DAN MAKAN Pembayaran balik bagi Bayaran Munasabah dan Biasa Diamalkan yang Perlu Dari Segi Perubatan untuk penginapan bagi bilik dan makanan. Jumlah manfaat hendaklah sama dengan bayaran sebenar yang dikenakan oleh Hospital semasa Orang yang Dilindungi dimasukkan ke hospital, tetapi manfaat tidak boleh melebihi, bagi mana-mana satu hari, kadar Manfaat Bilik dan Makan, dan bilangan maksimum hari seperti yang ditetapkan dalam Jadual Manfaat. Orang yang Diilindungi hanya layak menerima manfaat ini apabila dimasukkan ke Hospital sebagai pesakit dalam.2 UNIT RAWATAN RAPI Pembayaran balik bagi Bayaran Munasabah dan Diamalkan yang Perlu Dari Segi Perubatan untuk bilik dan makan yang sebenarnya ditanggung semasa dimasukkan ke hospital sebagai pesakit dalaman di Unit Rawatan Rapi Hospital. Bayaran manfaat ini hendaklah sama dengan bayaran sebenar yang dikenakan oleh Hospital tertakluk kepada manfaat maksimum bagi mana-mana satu hari, dan bilangan maksimum hari, seperti yang ditetapkan dalam Jadual Manfaat. Apabila tempoh dimasukkan ke hospital di Unit Rawatan Rapi melebihi tempoh maksimum yang ditetapkan dalam Jadual Manfaat, maka pembayaran balik akan dihadkan kepada kadar Bilik dan Makan Harian Hospital. Manfaat Bilik dan Makan Hospital tidak boleh dibayar bagi tempoh dimasukkan ke hospital tersebut apabila Manfaat Unit Rawatan Rapi Harian dibayar.3 BEKALAN & PERKHIDMATAN HOSPITAL Pembayaran balik bagi caj-caj yang ditanggung bagi Bayaran Munasabah dan Diamalkan yang Perlu Dari Segi Perubatan ke atas perkhidmatan penjagaan am, dadah dan ubat-ubatan yang dipreskripsi dan digunakan, membalut luka, alatan penganduh (splint), acuan plaster, sinar-x, ujian makmal, elektrokardiogram, fisioterapi, ujian metabolisma basal, suntikan dan larutan intravena, pengurusan darah dan plasma darah tetapi tidak termasuk kos darah dan plasma semasa Orang Yang Dilindungi dimasukkan ke hospital sebagai pesakit dalaman, hingga kepada amaun yang dinyatakan di dalam Jadual Manfaat.4 KHIDMAT RUNDINGAN & DIAGNOSIS PRA-PEMBEDAHAN Bayaran ke atas khidmat rundingan, patologi dan radiografi setelah dirujukkan oleh pengamal am bagi setiap penyakit atau kecederaan yang memerlukan pesakit dimasukkan ke hospital. Manfaat tidak akan dibayar bagi rawatan pesakit luar (termasuk perubatan dan mana-mana khidmat rundingan berikutnya selepas penyakit didiagnosis) dan tidak juga jika pesakit tidak menerima rawatan pembedahan selepas khidmat diagnosis telah dijalankan.5 RUNDINGAN PAKAR PRA-HOSPITAL Pembayaran balik bagi Bayaran Munasabah dan Biasa Diamalkan untuk rundingan kali pertama oleh Pakar yang berkaitan dengan Hilang Upaya mengikut bilangan hari maksimum seperti yang ditetapkan dalam Jadual Manfaat sebelum dimasukkan ke Hospital, dan dengan syarat rundingan itu Perlu Dari Segi Perubatan dan telah disyorkan secara bertulis oleh pengamal perubatan am yang memberikan rawatan. Bayaran tidak akan dibuat untuk rawatan klinikal (termasuk ubat dan rundingan berikutnya selepas penyakit didiagnosis) atau apabila Peserta tidak dimasukkan ke hospital untuk rawatan bagi keadaan perubatan yang didiagnosis itu. 22
  23. 23. 6 UJIAN DIAGNOSTIK PRA-HOSPITAL Pembayaran balik bagi Bayaran Munasabah dan Biasa Diamalkan untuk ECG, sinar-X dan ujian makmal yang Perlu Dari Segi Perubatan yang dijalankan di Hospital untuk tujuan diagnostik bagi kecederaan atau penyakit apabila berkaitan dengan Hilang Upaya sebelum dimasukkan ke hospital mengikut bilangan hari dan jumlah maksimum yang ditetapkan dalam Jadual Manfaat dan yang disyorkan oleh pengamal perubatan yang layak. Bayaran tidak akan dibuat jika dalam khidmat diagnostik itu, Peserta tidak perlu dimasukkan ke hospital untuk rawatan bagi keadaan perubatan yang didiagnosis itu. Bayaran ubat dan rundingan yang dikenakan oleh pengamal perubatan tidak akan dibayar.7 LAWATAN PAKAR PERUBATAN DALAM HOSPITAL Pembayaran balik bagi Bayaran Munasabah dan Biasa Diamalkan oleh Pakar Perubatan untuk lawatan yang Perlu Dari Segi Perubatan ke atas pesakit dalaman berbayar semasa dimasukkan ke hospital kerana hilang upaya bukan pembedahan dan tertakluk kepada maksimum satu (1) lawatan sehari tidak melebihi bilangan hari maksimum yang ditetapkan dalam Jadual Manfaat.8 RAWATAN SELEPAS PENGHOSPITALAN Pembayaran balik bagi Bayaran Munasabah dan Biasa Diamalkan yang ditanggung bagi rawatan susulan yang Perlu Dari Segi Perubatan oleh Pakar Perubatan yang sama yang telah memberikan rawatan, mengikut bilangan hari dan jumlah maksimum seperti yang ditetapkan dalam Jadual Manfaat sebaik sahaja selepas keluar dari Hospital kerana hilang upaya bukan pembedahan. Ini hendaklah termasuk ubat yang dipreskripsikan dalam rawatan susulan tetapi tidak boleh melebihi bekalan yang diperlukan untuk bilangan hari maksimum seperti yang ditetapkan dalam Jadual Manfaat.9 BAYARAN PEMBEDAHAN Pembayaran balik bagi Bayaran Munasabah dan Biasa Diamalkan untuk pembedahan yang Perlu Dari Segi Perubatan oleh Pakar, termasuk lawatan penilaian pra-pembedahan Orang Yang Dilindungi oleh Pakar dan rawatan selepas pembedahan hingga bilangan hari maksimum tiga puluh satu (31) hari dari tarikh pembedahan, tetapi dalam amaun maksimum yang dinyatakan dalam Jadual Manfaat. Jika lebih daripada satu pembedahan dijalankan bagi Mana-mana Satu Hilang Upaya, jumlah bayaran untuk semua pembedahan yang dijalankan, tidak boleh melebihi jumlah maksimum yang dinyatakan dalam Jadual Manfaat.10 PEMBAYARAN PAKAR BIUS Pembayaran balik bagi Bayaran Munasabah dan Biasa Diamalkan oleh Pakar Bius untuk pemberian bahan bius yang Perlu Dari Segi Perubatan tidak melebihi had yang ditetapkan dalam Jadual Manfaat.11 BAYARAN BILIK BEDAH Pembayaran balik bagi Bayaran Munasabah dan Biasa Diamalkan untuk Bilik Bedah yang berkaitan dengan prosedur pembedahan.12 BAYARAN AMBULANS Pembayaran balik bagi Bayaran Munasabah dan Biasa Diamalkan yang ditanggung untuk khidmat ambulans di rumah (domestik) (termasuk atendan) ke dan/atau dari Hospital di mana Orang yang Dilindungi itu dimasukkan ke hospital. Bayaran tidak akan dibuat jika Orang yang Dilindungi itu tidak dimasukkan ke hospital dan tertakluk kepada had yang ditetapkan dalam Jadual Manfaat.13 RAWATAN KECEMASAN KEMALANGAN, PESAKIT LUAR Pembayaran balik bagi Bayaran Munasabah dan Biasa Diamalkan yang ditanggung hingga jumlah maksimum yang dinyatakan dalam Jadual Manfaat, bagi kecederaan anggota badan yang dilindungi yang timbul daripada Kemalangan bagi rawatan yang Perlu Dari Segi Perubatan sebagai pesakit luar di mana-mana klinik atau hospital berdaftar dalam tempoh dua puluh empat (24) jam dari masa berlaku Kemalangan yang menyebabkan kecederaan anggota badan yang dilindungi. Rawatan susulan oleh doktor yang sama atau klinik atau Hospital berdaftar yang sama untuk kecederaan anggota badan yang dilindungi yang sama akan disediakan hingga jumlah maksimum dan bilangan hari maksimum seperti yang ditetapkan dalam Jadual Manfaat.14 RAWATAN KECEMASAN PERGIGIAN Pembayaran balik caj-caj sebenar yang ditanggung bagi rawatan gigi asli yang sihat akibat kecederaan kemalangan dan diterima sebagai pesakit luar dalam tempoh dua-puluh empat (24) jam kejadian kemalangan di klinik pergigian atau hospital yang berdaftar. Rawatan susulan oleh pakar pergigian yang sama di klinik pergigian atau hospital yang berdaftar akan diberi sehingga bilangan hari maksimum tiga puluh satu (31) hari. 23

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